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Surescripts Issues 2014 National Progress Report

Surescripts just released its 2014 National Progress Report, which always shines a national spotlight on electronic prescribing (ePrescribing).

The theme this year could be “ambulatory ePrescribing: game over, what’s next,” as it celebrates the industry’s success with ePrescribing, paints a picture of what’s still to be done and begins to make the case for how successful ePrescribing can translate to other areas of health information technology (healthIT).

Interestingly, the title doesn’t even mention “ePrescribing,” nor did the term headline a specific section this year. The contents fall into three categories: company highlights, brief summaries of the status of a handful of transactions, and an appendix that contains a summary chart for selected transactions and a chart for rankings by state of their percentage of ePrescribing of controlled substances (EPCS). The format is a slick chart book with a marketing brochure feel, replete with graphics and brief rundowns of selected accomplishments.

Company highlights. A good bit of this year’s report is devoted to Surescripts’ promotional highlights. In fact, its very first section emphasizes the breadth of the company’s connectedness among a long list of stakeholders. Other sections address:

Optimization. Surescripts touts moving from “adoption to optimization” in 2014. This is depicted by a chart characterizing growth in transaction volume as adoption and utilization from 2005 to 2013 and optimization going forward. Optimization is defined as adding new functionality and improving data quality. Such value-adds as interoperability, new transactions and improved prescription quality will continue to drive transaction volume. Such efforts are expected to intensify industrywide due to individual activities by vendors, intermediaries and standards development organizations to create value and innovation. Bigger-picture initiatives created by industry associations and the government — such as meaningful use (MU) and the new interoperability program launched by the Office of the National Coordinator for Health Information Technology (ONC) — also will contribute to making ePrescribing an increasingly integral and valuable part of patient care.

Clinical messaging. The growth of clinical messaging — one of Surescripts’ expanding lines of business — is highlighted. According to a separate data set chart, the company processed a total of 7.4 million clinical messages in 2014 and 974 hospitals were users. Ambulatory providers obviously contributed to the total, but they are not mentioned. Clinical messaging is a valuable transaction to some stakeholders. However, it is one of a host of new or improved transactions and tools, such as clinical decision support, that will create value and become a must-have for value-based care.

Improving “public health through fraud prevention.” ePrescribing’s potential to reduce fraud and prescription drug abuse has been acknowledged as early as 2005. This is important and still true today. Now that technology and infrastructure have advanced, policy makers are taking advantage of ePrescribing’s potential to help address the nation’s opioid drug abuse epidemic through such programs as New York’s Internet Systems for Tracking Over-Prescribing (I-STOP). It mandates that all prescriptions be sent electronically beginning March 2016 (the implementation date was moved back). Similar programs are expected to spring up nationwide. The promise of ePrescribing to improve public health is a topic that merits its own write-up, but was not covered in this year’s report, even though public health is given as a subtitle.

Selected Transactions. The report’s real meat lies in write-ups about three specific transactions.

Medication history. The section on medication history is an example of the report’s change in focus. The narrative suggests a benefit of ePrescribing lies in making available access to real-time prescription data at the point of care — especially for hospitals’ use in medication reconciliation. The savings to hospitals from medication reconciliation are estimated for a range of facilities, such as $11,704 for a small (100-bed) hospital to $1.1 million for a very large (1,000+ bed) facility. Such figures are guaranteed to get hospitals’ attention, especially the bigger ones with deeper pockets. It is not clear how the estimates were derived as many factors must be taken into account to conduct such an analysis. For example, pharmacy claims data are more robust that medical claims data, but it’s unclear how many pharmacies contributed to the analysis.

In terms of transaction volume, Surescripts concentrated on the hospital side of the equation. The chart in the appendix indicated that the number of hospitals conducting medication history transactions more than doubled in 2014. However, hospital volume accounted for approximately 11% of the 764 million total medication history transactions.

The report also does not discuss improving prescription quality by addressing problems associated with medication history, including data accuracy and availability. The first step toward optimizing ePrescribing’s value for medication reconciliation is an analysis of how to overcome such data and process deficiencies. Then, the brains behind healthIT can figure out ways to better conduct electronic medication reconciliation and tackle transitions of care.

Electronic prior authorization. Surescripts also sets the stage for electronic prior authorization (ePA) of medications as a value-add. The write-up briefly discusses some of the problems with manual PA and offers estimates of ePA savings: 4 hours per pharmacist per week or $11,000 per pharmacist per year; 5 to 8 hours per physician each week, translating to $14,000 per physician per year.

Regardless of how they are computed, those savings can make such an ePA product attractive to big chains and large group practices. Everyone needs to wring out efficiencies from the overhead, so the report shines a light on this often overlooked opportunity to save money. The patient safety aspect of ePA was mentioned in passing, with ePA cited as a means to minimize abandoned prescriptions resulting from the hassles associated with the manual PA process.

Electronic Prescribing for Controlled Substances (EPCS). New this year is a report out on EPCS, which is a good news-bad news story. The good news is that EPCS is now legal in 50 states and the District of Columbia (Missouri very recently adopted rules in support of EPCS that will become effective in July). Transaction volume rose 400% in 2014 to 1.6 million controlled substance ePrescriptions routed through the Surescripts network. The bad news is that only roughly three-quarters of pharmacies can receive EPCS (although that number increased since 2013) and only 1.4% of providers were enabled.

Interestingly, Surescripts just announced at the 2015 HealthDataPalooza (May 31 – June 3) that 3% of providers are now enabled to send electronic prescriptions for controlled substances. While this is still only 3%, it’s encouraging to see this start to take off due to mandatory use of such programs as with New York’s I-STOP. The future for EPCS is bright as physicians will have to prescribe controlled substances electronically if they are to meet the higher ePrescribing thresholds that will be required for MU stage 3 (the current proposal is 80%). EPCS also will be key for providers in certain specialties, such as oncology, which have many patients using controlled substances.

Transaction data. The appendix is divided into two sets of summary charts, one of which provides data for selected transactions. This is the only place to find data regarding traditional ambulatory ePrescribing per se. Surescripts routed 1.2 billion ePrescriptions in 2014 and more than two-thirds were new prescriptions.

This chart also contains a confusing statistic about percentage of ePrescribers. Surescripts claims the percentage inched upward to 56% in 2014 from 55% the previous year. According to last year’s report, roughly three-quarters of ambulatory providers were ePrescribing in 2013. The discrepancy is likely due to the inclusion of all prescribers — acute and ambulatory — this year, but “chart book” format has precious little explanation, unlike in past years. To those who pay attention, it makes it appear as though we have gone significantly backward when, in fact, progress continues to be made. Sources outside the report that nearly 80% of ambulatory providers are ePrescribing.

State rankings based on EPCS. The second summary chart in the appendix shows state rankings on the basis of EPCS — the percentage of prescribers enabled to conduct EPCS, the percentage of pharmacies enabled to receive EPCS and the percentage of EPCS prescriptions. This stands in contrast to last year, when the rankings recognized utilization of ePrescribing based on volume of use of Surescripts’ prescription benefit, medication history and prescription routing services.

The top 10 states using EPCS include many of those adopting ePrescribing early, such as Delaware, Massachusetts and Rhode Island. However, Nebraska was in the middle of the pack on traditional ePrescribing but topped the EPCS list this year, followed by California (which, ironically, has been near the bottom of the traditional ePrescribing state rankings). Both have nearly 9% of prescribers and more than 70% of pharmacies enabled. Nebraska has 6.9% EPCS transaction volume, with California a distant second at 4.3%. New York ranks 21st, with 1.9% of prescribers and 70.3% of pharmacies enabled, but less than 1% of EPCS transactions. Obviously, New York has a long way to go in the way of EPCS if providers are going to meet I-STOP’s March 2016 go-live date. Surescripts has done a huge service by shining a light on the embryonic state of EPCS, which will be useful to vendors and policy makers going forward.

What’s missing. Several pieces are missing or not specifically called out. They include:

Formulary and benefit. Precious little about the critically important aggregate flat file that Surescripts distributes using the NCPDP Formulary and Benefit (F&B) standard is found in this year’s report despite concerns from prescribers about the accuracy of formulary data. One deficient area that could be tracked is the PA flag.

There is also nothing about the real-time benefit check (RTBC), which promises to add accuracy and clarity to the group-level F&B paradigm. Both have implications for curbing costs and, arguably, improving health care by increasing formulary compliance and medication adherence. Research has shown that high out-of-pocket costs are a main reason why patients abandon prescriptions.

Specialty pharmacy. Specialty prescribing also is not covered, but that is not surprising because these prescriptions are low in volume in the overall scheme of things and the prescription process is not yet automated enough to merit a mention in Surescripts’ report. However, that is due to change in the near future because of the importance of specialty medications as high-cost drivers of the nation’s drug spend, with specialty medication outlays expected to quadruple to $402 billion by 2020, and the strides being made in the industry to bring specialty prescribing into the electronic age.

Specialty prescription drugs — those used to treat chronic, complex diseases such as cancer, multiple sclerosis and rheumatoid arthritis — have historically been associated with rare medical conditions. However, they are being used more frequently for the treatment of such common chronic conditions as rheumatoid arthritis and multiple sclerosis. According to a recent study, specialty drugs in 2013 accounted for less than 1% of US prescriptions but for more than 25% of prescription spending. Specialty drugs also are associated with greater costs — with a $12,238 median over a treatment period versus $784 for traditional drugs. In actual terms, some specialty therapies can easily exceed $10,000 per patient per year.

As a result, specialty prescribing is on the radar of payers, patients and policy makers who are looking for a balance between the high costs of specialty medications and their many benefits related to health and quality of life. Moreover, it is ripe for automation. People tend to view specialty prescribing as a single transaction while it is, in fact, a series of transactions done mostly by paper, phone and fax. Enter ePrescribing. Standards and ePrescribing infrastructure already are available to handle the basic prescription process. Other necessary pieces, such as ePA, are emerging that will facilitate automation of other specialty prescribing processes. The industry is working to fill in the gaps, which will put specialty ePrescribing on the map in the near future.